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Basic for HSA plan (Bronze level)

Basic for HSA plan (Bronze level)

Blue Shield pays, on average, 60% of covered medical expenses

Our Basic plan for health savings accounts is perfect for those who want low monthly rates and to better manage their healthcare spending through a health savings account (HSA). With this HSA-compatible*, high-deductible health plan, you can prepare for future medical costs by contributing pre-tax money to your own savings account for healthcare expenses. You’ll even enjoy preventive care before meeting the deductible.

This plan is available for purchase directly through Blue Shield or through Covered California.

Basic for HSA plan (Bronze level) – Benefit Overview

Benefit Participating providers1 (PPO and EPO): Non-participating providers1 (PPO only):
Office visit - primary care doctor 40% 50%
Office visit - specialist doctor 40% 50%
Urgent care visit 40% 50%
Preventive health benefits $02 Not covered
Inpatient hospitalization 40% 50%
Outpatient surgery 40% 50%
Lab 40% 50%
X-ray 40% 50%
Emergency room services not resulting in admission 40% 40%
Maternity 40% 50%
Generic drugs 40%4 Not covered
Preferred brand drugs 40%4 Not covered
Non-preferred brand drugs 40%4 Not covered
Chiropractic Not covered Not covered
Acupuncture
(from a licensed acupuncturist)
40% 40%
Pediatric eye exam $02 Up to $302
Pediatric eyeglasses $02 $55 single vision2
Calendar-year medical deductible3 $4,500 per individual / $9,000 per family $4,500 per individual / $9,000 per family
Calendar-year out-of-pocket maximum
(includes deductible)
$6,350 per individual / $12,700 per family $9,350 per individual / $18,700 per family
Calendar-year brand drug deductible $04 Not covered

Get complete health plan details

For complete plan details on our Basic PPO for HSA and Basic EPO for HSA plans, see the Benefit Summaries and Legal Disclosures below:

Benefit Summary for Basic PPO for HSA (PDF, 477KB)
Benefit Summary for Basic EPO for HSA (PDF, 466KB)

Legal Disclosure (PDF, 916KB)

We also have Summary of Benefits and Coverage Forms that can help you make a decision by providing you with an easy to understand overview of what these plans cover. Visit blueshieldca.com/sbc to obtain the forms.

Pediatric dental

Pediatric dental is an essential health benefit for children under age 19, and must be purchased when applying for a medical plan directly through Blue Shield. We offer four pediatric dental plans to choose from. Download our pediatric dental plans flier for more information.

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